Intensive Care Med (2014) 40:129–130 DOI 10.1007/s00134-013-3137-z
LETTER
Intracyte gelÒ with TelfaÒ were used There are few documented incidences of extravasations of propofol on the wound. During his stay, the patient devel- resulting in injury producing tissue necrosis [1–4]. The effects of the oped an elevated white blood cell count and temperature. Broad-spec- infusion were seen quite quickly trum antibiotic coverage was initiated (within 2 days). In one case report, Tissue necrosis after propofol after consultation with the infectious the deconditioned nature of the diseases service. Deep tissue cultures patient secondary to undernutrition extravasation revealed coagulase-negative Staphy- and septic shock were thought to contribute to the necrosis induced by lococcus with scant yeast, propofol [3]. Our patient had periphsubsequently growing Candida eral vascular disease and diabetes, albicans. Accepted: 10 October 2013 which may have predisposed him to One week after the incident, the Published online: 6 November 2013 Ó Springer-Verlag Berlin Heidelberg and necrotic fat and fascia overlying the injury and delayed healing. ESICM 2013 To contain the amount of damage biceps as well as thrombosed portions of the basilic and cephalic veins were some authors recommend attempting aspiration of the fluid before needle debrided (Fig. 1). The wound was irrigated with a betadine-containing withdrawal, as well as using Ringer’s solution and packed open. Eventually, solution or saline as a ‘‘flush-out’’ Dear Editor, a vacuum-assisted closure device was within 24 h of the injury [2, 4, 5]. We describe a case of an adverse put in place, and subsequent assess- This requires a proximal incision to event in which significant tissue ments indicated the base of the wound the area where a cannula is inserted necrosis resulted in a 56-year-old into the subcutaneous space. The male after extravasation of propofol appeared to be healthy. The wound solution is then infiltrated and continued to improve, and on postfollowing elective vascular repair for allowed to drain. Depending on the operative day 71, the wound was bilateral iliac aneurysms. The extent of the injury, debridement may approximated with a Steri-Strip creep patient’s past medical history was be necessary. method, where the normal skin was significant for peripheral vascular Considering the frequency of the disease, diabetes mellitus, and ische- pinched together and Steri-Strips use of propofol in the ICU setting, applied to the edge. On post-operative mic heart disease. His postoperative this report highlights the need for day 119, the area had completely course was problematic, requiring careful monitoring of intravenous healed, and the patient was dismultiple surgeries for complications. lines containing propofol. charged home 7 days later. On postoperative day 10 of his stay in the intensive care unit (ICU) he remained intubated and sedated, and propofol (10 mg/mL in 10 % lipid solution; AstraZeneca, Ontario, Canada) was infused interstitially in the left antecubital fossa site. It had been running alone through this dedicated line, and it was unknown how much volume was involved. The area which ultimately sloughed skin was found to be indurated. The infusion was stopped and the area treated conservatively. Over the next few days, the patient developed left arm cellulitis, skin sloughing, and purulence in a 5.1 9 5.1-cm area around the site. Initially, the area of necrosis seemed to be 5 9 3.5 cm. Daily washing, saline dressings, and Fig. 1 Area of injury of the patient’s arm secondary to extravasation Jaclyn M. LeBlanc Donald Lalonde Kayla Cameron John A. Mowatt
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3. Tokumine J, Sugahara K, Tomori T, Consent was obtained from the Nagasawa Y, Takaesu Y, Hokama A patient and the local research ethics (2002) Tissue necrosis caused by board for the publication of this report extravasated propofol. J Anesth and the image contained herein. 16:358–359 Conflicts of interest
None.
References 1. Abdelmalak BB, Bashour CA, Yared JP (2008) Skin infection and necrosis after subcutaneous infiltration of propofol in the intensive care unit. Can J Anaesth 55:471–473 2. Roth W, Eschertzhuber S, Gardetto A, Keller C (2006) Extravasation of propofol is associated with tissue necrosis in small children. Paediatr Anaesth 16:887–889
K. Cameron Department of Pharmacy, Saint John Regional Hospital, Saint John, NB, Canada e-mail: [email protected]
4. Mahajan R, Gupta R, Sharma A (2006) Extravasation injury caused by propofol. J. A. Mowatt Anesth Analg 102:648 5. Gault DT (1993) Extravasation injuries. Department of Surgery, Saint John Regional Hospital, Saint John, NB, Canada Br J Plast Surg 46:91–96 e-mail: [email protected] J. M. LeBlanc ()) Dalhousie Medicine New Brunswick, Dalhousie University, PO Box 5050, 100 Tucker Park Road, Saint John, NB E2L 4L5, Canada e-mail: [email protected] D. Lalonde Dalhousie University, Saint John, NB, Canada e-mail: [email protected]
LETTER
Intracyte gelÒ with TelfaÒ were used There are few documented incidences of extravasations of propofol on the wound. During his stay, the patient devel- resulting in injury producing tissue necrosis [1–4]. The effects of the oped an elevated white blood cell count and temperature. Broad-spec- infusion were seen quite quickly trum antibiotic coverage was initiated (within 2 days). In one case report, Tissue necrosis after propofol after consultation with the infectious the deconditioned nature of the diseases service. Deep tissue cultures patient secondary to undernutrition extravasation revealed coagulase-negative Staphy- and septic shock were thought to contribute to the necrosis induced by lococcus with scant yeast, propofol [3]. Our patient had periphsubsequently growing Candida eral vascular disease and diabetes, albicans. Accepted: 10 October 2013 which may have predisposed him to One week after the incident, the Published online: 6 November 2013 Ó Springer-Verlag Berlin Heidelberg and necrotic fat and fascia overlying the injury and delayed healing. ESICM 2013 To contain the amount of damage biceps as well as thrombosed portions of the basilic and cephalic veins were some authors recommend attempting aspiration of the fluid before needle debrided (Fig. 1). The wound was irrigated with a betadine-containing withdrawal, as well as using Ringer’s solution and packed open. Eventually, solution or saline as a ‘‘flush-out’’ Dear Editor, a vacuum-assisted closure device was within 24 h of the injury [2, 4, 5]. We describe a case of an adverse put in place, and subsequent assess- This requires a proximal incision to event in which significant tissue ments indicated the base of the wound the area where a cannula is inserted necrosis resulted in a 56-year-old into the subcutaneous space. The male after extravasation of propofol appeared to be healthy. The wound solution is then infiltrated and continued to improve, and on postfollowing elective vascular repair for allowed to drain. Depending on the operative day 71, the wound was bilateral iliac aneurysms. The extent of the injury, debridement may approximated with a Steri-Strip creep patient’s past medical history was be necessary. method, where the normal skin was significant for peripheral vascular Considering the frequency of the disease, diabetes mellitus, and ische- pinched together and Steri-Strips use of propofol in the ICU setting, applied to the edge. On post-operative mic heart disease. His postoperative this report highlights the need for day 119, the area had completely course was problematic, requiring careful monitoring of intravenous healed, and the patient was dismultiple surgeries for complications. lines containing propofol. charged home 7 days later. On postoperative day 10 of his stay in the intensive care unit (ICU) he remained intubated and sedated, and propofol (10 mg/mL in 10 % lipid solution; AstraZeneca, Ontario, Canada) was infused interstitially in the left antecubital fossa site. It had been running alone through this dedicated line, and it was unknown how much volume was involved. The area which ultimately sloughed skin was found to be indurated. The infusion was stopped and the area treated conservatively. Over the next few days, the patient developed left arm cellulitis, skin sloughing, and purulence in a 5.1 9 5.1-cm area around the site. Initially, the area of necrosis seemed to be 5 9 3.5 cm. Daily washing, saline dressings, and Fig. 1 Area of injury of the patient’s arm secondary to extravasation Jaclyn M. LeBlanc Donald Lalonde Kayla Cameron John A. Mowatt
130
3. Tokumine J, Sugahara K, Tomori T, Consent was obtained from the Nagasawa Y, Takaesu Y, Hokama A patient and the local research ethics (2002) Tissue necrosis caused by board for the publication of this report extravasated propofol. J Anesth and the image contained herein. 16:358–359 Conflicts of interest
None.
References 1. Abdelmalak BB, Bashour CA, Yared JP (2008) Skin infection and necrosis after subcutaneous infiltration of propofol in the intensive care unit. Can J Anaesth 55:471–473 2. Roth W, Eschertzhuber S, Gardetto A, Keller C (2006) Extravasation of propofol is associated with tissue necrosis in small children. Paediatr Anaesth 16:887–889
K. Cameron Department of Pharmacy, Saint John Regional Hospital, Saint John, NB, Canada e-mail: [email protected]
4. Mahajan R, Gupta R, Sharma A (2006) Extravasation injury caused by propofol. J. A. Mowatt Anesth Analg 102:648 5. Gault DT (1993) Extravasation injuries. Department of Surgery, Saint John Regional Hospital, Saint John, NB, Canada Br J Plast Surg 46:91–96 e-mail: [email protected] J. M. LeBlanc ()) Dalhousie Medicine New Brunswick, Dalhousie University, PO Box 5050, 100 Tucker Park Road, Saint John, NB E2L 4L5, Canada e-mail: [email protected] D. Lalonde Dalhousie University, Saint John, NB, Canada e-mail: [email protected]
